Thursday, July 4, 2013

Drug abuse and pain

The headlines might cry about a "300percent increase in drug deaths" from opiods, but the picture is actually quite different.

CDC report on the problem:

Results: In 2010, a total of 15,323 deaths among women were attributed to drug overdose, a rate of 9.8 per 100,000 population. Deaths from opioid pain relievers (OPRs) increased fivefold between 1999 and 2010 for women; OPR deaths among men increased 3.6 times. In 2010, there were 943,365 ED visits by women for drug misuse or abuse. The highest ED visit rates were for cocaine or heroin (147.2 per 100,000 population), benzodiazepines (134.6), and OPR (129.6). ED visits related to misuse or abuse of OPR among women more than doubled between 2004 and 2010.

when there are almost a million Emergency room visits for drug abuse, there is a problem.

But the increase in percentage is high, yet the numbers are not:

In 2010, a total of 15,323 deaths among women were attributed to drug overdose, a rate of 9.8 per 100,000 population. Among these, a drug was specified in 10,922 (71.3%) deaths. One or more prescription drugs were involved in 9,292 (85%) of the drug-specified deaths among women, and OPRs were involved in 6,631 (71.3%) of the prescription drug overdose deaths. These numbers represent substantial increases from 1999 (5,591 drug overdose deaths among women and 1,287 OPR overdose deaths). The percentage increase in number of OPR overdose deaths was 415% for women and 265% for men.
 so the numbers involved are in the thousands, yet given the large population we are talking about (280 million Americans, or even from the 1 million overdose problems seen in the ER) the actual numbers are not that high.

But how many of these were from accidental drug overdose? Or from suicide? or from taking them to get high?

The article admits they don't know.

information on the motivation for use might be incomplete; some ED visits might have resulted from suicide attempts. Finally, distinguishing between drugs taken for nonmedical and medical reasons is not always possible, especially when multiple drugs are involved. 

The long acting medicines are especially prone to overdose, since they take awhile to work, and then may accumulate their effects after the person takes a second dose. Those with other problems are also vulnerable: I've had two women with COPD (chronic lung problems) who had to be "rescued" after their fentenyl patches slowed their respirations, even though they had tolerated the same patch dosage for a couple weeks for chronic pain.

But then I had a druggie overdose on some MSContin she stole from her relative dying of cancer. Again, she didn't get high so took a few too many.

So how many of these pills were "diverted" or stolen? Our reservation's casino had an ongoing market for Tylenol with codiene. (usual price was only 5 dollars a pill, much less than if you bought it on the street in the nearby town)....

Our old ladies would sell a few if they were short of  money, but they also knew that they could buy a few if they hurt too much and didn't want to sit in the emergency room for a couple of hours. Go figure.

Then there was the teenager "offered" a swig of another teen's grandmom's morphine syrup (grandmom had died, but the teen found a small bottle in the glove compartment of the car, for breakthrough pain).

Then there was the druggie with lupus. She'd come in with red swollen joints barely able to move, yet was unreliable in taking her medicine... We finally "solved" her problem with a strict pain contract that would only give her pills if she took her methotrexate dose in the clinic, after we had done her blood tests. That worked, but she had withdrawal symptoms when she developed pneumonia (a problem since her immune system was a mess). So what should we have done about her? Let her suffer? 


so what is the alternative for those with chronic pain?

NSAIDS? (motrin/ibuprofen, alleve, aspirin?)

the dirty little secret is that we see more problems from them than narcotics (usually bleeding ulcers, but also kidney problems)

LINK emedicine

Both acute and chronic poisoning with NSAIDs results in significant morbidity and mortality. The Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) system has estimated that more than 100,000 hospitalizations and more than 16,000 deaths in the United States each year are due to NSAID-related complications with costs greater than $2 billion. Gastrointestinal (GI), renal, central nervous system (CNS), hematologic, and dermatologic symptoms may ensue (see Complications).

that has led some to tell old ladies to take tylenol instead for their pain.

But the dirty little secret is that you have to take a lot of them, and yes, you can also run into problems with tylenol. ( Acetaminophen, paracetamol).

The main dirty little secret is that if you overdose on it, you don't die right away: You die a few days later when your liver shuts down. Yes, it can be treated if a doc knows about it and gives you the antidote, but often the suicidal person might not present to the ER.

Luckily, such deaths are rare:
Analysis of national databases show that acetaminophen-associated overdoses account for about 56,000 emergency room visits and 26,000 hospitalizations yearly. Analysis of national mortality files shows 458 deaths occur each year from acetaminophen-associated overdoses; 100 of these are unintentional. The poison surveillance database showed near-doubling in the number of fatalities associated with acetaminophen from 98 in 1997 to 173 in 2001. AERS data describe a number of possible causes for unintentional acetaminophen-associated overdoses.
 All the textbooks assure us that tylenol works "as good" as other medicines. well, that's true: but the half life means you have to take it every four to six hours. Me, I prefer to take one naprosyn which lasts 24 hours, and pop an omeprazole if it causes heartburn.

I remember one doc who gave an impassioned plea about not using ibuprofen (another "NSAID") for pain, after he had discussed the increase in kidney transplants for "analgesic nephropathy". 
at the end of the talk, when someone pointed out that tylenol just doesn't work as well as Motrin(ibuprofen) and asked him what he took for pain, he admitted he too ibuprofen, but tried not to take it often.

So should we just sit and hurt?

That can cause depression, obesity, and suicide.

No, I don't have an answer for this, but I'm not a good one to ask: I don't get high on oxycodone, and I get better pain relief with NSAIDS than codiene.

as for studies on what works for pain and what doesn't: The placebo effect is huge here.

in experiments, the only pain medicine that "statistically" is better than placebo is...injected morphine.

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